Fewer financial resources, but not education, tied to increased risk

Action Points

Older English adults with fewer financial resources were at higher risk of developing dementia.

The study found no association between educational attainment and increased risk.

Older English adults with fewer financial resources were at higher risk of developing dementia, a longitudinal prospective cohort study found.

In a sample representative of the English population, the rate of developing dementia was 1.68 times higher for those in the lowest wealth quintile group when compared with those in the highest (HR 1.68, 95% CI 1.05-2.86), reported Dorina Cadar, PhD, of University College London, and colleagues, in JAMA Psychiatry.

Although rates of dementia are on the decline by roughly 20% in the U.S. and UK, according to the Framingham Heart Study, it remains a significant and costly public health concern.

Education and wealth were used as individual markers of socioeconomic status (SES), and group level characteristics were explored through the Index of Multiple Deprivation (IMD), a composite measure that combines area-level socioeconomic status indicators into a single deprivation score.

Higher hazards were also observed for those in the second highest quintile of IMD (HR 1.62, 95% CI 1.06-2.46) versus the least deprived quintile. The study found no association between educational attainment and increased risk.

"This is the first longitudinal study to examine multiple facets of SES characteristics at individual and group levels simultaneously in association with dementia incidence within an age cohort context," the authors wrote.

Data was drawn from 6,220 individuals recruited from the English Longitudinal Study of Ageing (ELSA). Participants were included if they were ages ≥65 and free of dementia at their baseline assessment either in wave 1 (2002-2003) or at the refreshment sample of wave 4 (2005-2006).

The baseline median age was 73, 55% were female, 59.2% married, and 52.5% were without formal educational qualifications.

Dementia occurrence was determined using an algorithm based on a combination of self- or informant-reported physician diagnosis of dementia or Alzheimer's disease, or a score above the threshold of 3.38 on the 16-question Informant Questionnaire on Cognitive Decline in the Elderly.

Educational attainment was measured through four categories ranging from lack of formal qualifications to having a university degree or higher. Wealth indices for the study quintiles were calculated by summing together assets from property, possessions, housing, investments, savings, artwork, jewelry, and net of debt.

The study also examined the relationship between markers of SES and risk of dementia in two independent age groups. Those born between 1902 and 1925 (cohort 1) and those born between 1926 and 1943 (cohort 2) A higher correlation was found between education, wealth, and risk of dementia in those born between 1926 and 1943, although the finding was not statistically significant.

The researchers suggested that those born before World War II may have benefited from opportunities created during the post-war period for access to more intellectually challenging jobs, and subsequent financial and social growth.

Previous studies have explored the role of education as a risk marker for development of dementia, with higher educational attainment associated with lower risk.

The researchers did not minimize these studies, but made the insightful observation that, "given that education is typically completed many decades before dementia onset, other individual and area-based components of SES such as wealth, income, and area deprivation, may provide a more accurate indication of current socioeconomic resources."

It was proposed that financially better-off older adults might have increased access to beneficial health resources and cultural opportunities that "allow them to remain actively engaged with the world," Cadar wrote in an email to MedPage Today. "We hope our findings help inform public health strategies for dementia prevention, evidencing why socioeconomic gaps should be targeted to reduce health disparities and enhance engagement in socio-cultural activities that ultimately contribute to a higher mental resilience or cognitive reserve."

When asked about the landscape for dementia drug development, Cadar emphasized that dementia is incurable. So far, treatments only delay ultimate decline. "Yes, we all keep hoping for a miracle drug to fix dementia or any other medical condition, but we tend to underestimate the role of environmental and lifestyle behaviors," she commented.

Study limitations included the possibility of dementia underdiagnosis, the barrier to a race/ethnicity analysis, given that participants were 97% white, and that dementia was not explored by specific typology.

As far as implications for future practice, Cadar told MedPage Today, "Public health strategies for dementia prevention should target socioeconomic gaps to reduce health disparities and protect those who are particularly disadvantaged, in addition to addressing vascular risk factors such as hypertension, diabetes mellitus, smoking, and heart disease."

The study was supported by the National Institute on Aging.

The English Longitudinal Study of Ageing is funded by the National Institute on Aging, by a consortium of UK government departments coordinated by the Economic and Social Research Council (ESRC) and the Office for National Statistics.

Cadar and co-authors disclosed no relevant relationships with industry. One co-author disclosed support from the UK Medical Research Council.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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